Older people with social care needs and multiple long-term conditions

In November 2015, the National Institute for Health and Care Excellence (NICE) in the UK published a guideline on care and support for older people with social care needs and multiple long-term conditions. The guideline recommends that care should be integrated and person-centred, while at present “some people are still being treated as a collection of conditions or symptoms, rather than as a whole person”. NICE calls for a designated care coordinator who would serve as the older person’s first point of contact as well as communicate with all health and social care services, including those provided by non-governmental organizations. Moreover, care should be supported by community-based multidisciplinary teams, which might include “a community pharmacist, physiotherapist or occupational therapist, a mental health social worker or psychiatrist, and a community-based services liaison worker”. The guideline also calls for health and social care providers to support the person with respect in ...

Developing care for a changing population: Supporting patients with costly, complex needs

Patients with multiple chronic conditions are a challenge for health care organization. In this report, it is offered a review of the most recent evidence regarding new models of care, and they are summarized in 10 points: (I) There are no specific ‘European’ answers to the problem of high cost/complexity, but a growing body of policy-relevant evidence is emerging, (II) Multifaceted interventions seem to work best for complex problems , (III) Identifying who is at risk of complexity is a crucial first step , (IV) The needs of patients identified as ‘complex’ are likely to vary considerably , (V) Good outcomes for complex patients need to be rooted in patient preferences and are likely to include non-medical goals, (VI) Interventions may not reduce high costs, at least in the short term, (VII) Chronic care models may not be fit for purpose for complex patients, (VIII) Although highly relevant, the implications for the ...

Implementing integrated care for multi-morbidity: analysis of experiences in 17 European programmes

Many countries are experimenting with new models of care provision and numerous integrated care programmes have been established internationally. However, little information is available on how to implement integrated care. The aim of this study was to provide more in-depth insights in the implementation of integrated care for developers and managers of integrated care programmes, policy makers, health insurers, and researchers.

Learning from long COVID: integrated care for multiple long-term conditions

Long COVID is a multisystem condition requiring a range of medical, therapeutic, and psychological inputs. Given the complexity of the illness affecting multiple organ systems, often impacting physical and mental health, individuals can be heavy healthcare users across primary, secondary, and emergency services.

The long COVID clinics commissioned in England have provided an opportunity to innovate within a complex care pathway, bringing multiple providers together to meet needs broader than has been historically possible for many other complex conditions. Designing these new services from a blank page has enabled teams to co-create services with patient groups and work more effectively in an integrated way. Significant benefits have been seen, including skills transference between professions.